MODULE 11: NEW YORK STATE SENIOR MEDICARE PATROL (SMP) HEALTH CARE FRAUD, WASTE AND ABUSE

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1 MODULE 11: NEW YORK STATE SENIOR MEDICARE PATROL (SMP) HEALTH CARE FRAUD, WASTE AND ABUSE Project Goals Empowering Seniors to Prevent Healthcare Fraud. To raise awareness of and prevent Medicare and Medicaid Fraud and Abuse. To ensure that beneficiaries of these programs receive both quality care and appropriate services. Protect, Detect and Report Training Objectives As a result of this training session, Health Insurance Information, Counseling, and Assistance Program (HIICAP) counselors will be able to: Understand and describe the mission of SMP. Understand and explain healthcare fraud and abuse. Provide information to identify and report health care fraud and abuse including SMP s tollfree phone number Provide information about the existence, extent and cost of Medicare and Medicaid fraud and abuse. Educate the community to protect, detect and report health care fraud and abuse. Overview SMP is a long-term initiative to fight fraud and abuse in Medicare and Medicaid. It officially started on April 1, 1995 as a two-year demonstration project that developed innovative ways to fight fraud, waste, error and abuse in the five states with the largest Medicare and Medicaid benefit payments. The five states included in the initial demonstration were New York, California, Illinois, Florida, and Texas. These states together accounted for 33 percent of all people with Medicare and 38 percent of all Medicare payments in the United States. The five targeted states contained 38 percent of all Medicaid recipients and 41 percent of all Medicaid payments in the United States. SMP represents the introduction of the partnership model in fighting fraud and abuse in Medicare and Medicaid. SMP established alliances with the New York State s Department of Health, Office of Children and Family Services, Attorney General s Office, Division of Criminal Justice, Office of the Comptroller, Medicaid Inspector General, Department of Financial Services, and the Medicare contractors and carriers. Partnerships establish methods for more efficient, global volunteer efforts; and they ensure advocacy with a unified voice for policy improvements in the State s health care system, including solutions for health care system problems. SMP also combines the efforts of three agencies within the U.S. Department of Health and Human Services the Centers for Medicare & Medicaid Services (CMS), the Administration on Aging (AoA), and the Office of Inspector General (OIG) and several other federal agencies, including the Department of Justice (DOJ), the Federal Bureau of Investigation (FBI), United States Attorney s Offices and Medicare contractors HIICAP NOTEBOOK 11-1

2 SMP continues to exist as a focused effort to eliminate fraud and abuse in the Medicare and Medicaid programs. SMP is designed to educate and empower the pubic and the aging network about how to protect, detect and report Medicare and Medicaid fraud and abuse. New York State will continue to identify, prevent and eliminate fraud and abuse in the Medicare and Medicaid programs, and educate people with Medicare and the public to avoid abuse in these programs. There are now SMP projects in every state, and Washington D.C., Puerto Rico, the U.S. Virgin Islands, and Guam. In New York State, National Government Services has agreed to be the clearinghouse for allegations of fraud and abuse received through the efforts of SMP. If your client suspects Medicare fraud, he or she may call SMP at For additional information on SMP, to report suspected fraud or abuse or to request a speaker about Medicare and Medicaid fraud, you may also contact SMP at Remember: When in doubt, let Medicare check it out! HOW MUCH MONEY IS LOST TO MEDICARE FRAUD AND ABUSE? The U. S. Office of Inspector General estimates that Medicare and Medicaid lose billions of dollars each year due to errors, fraud, waste, and abuse. Both the multiple systems for disbursing funds and the magnitude of health-care expenditures increase the probability of errors and create opportunities for fraud and abuse. The good news is that due to a joint initiative between the Department of Justice and the Department of Health and Human Services the government has recovered nearly 10 billion taxpayer dollars in the last 3 years. Fighting health care fraud and abuse saves money and protects patients. We all share a practical interest in the preservation of the Medicare program - we want Medicare to be there for us when we need it. Remember that people with Medicare are among the most vulnerable - the elderly and the disabled. WHAT IS MEDICARE FRAUD AND ABUSE AND WHAT IS THE DIFFERENCE? Fraud Fraud is the intentional deception or misrepresentation that an individual makes, knowing it to be false and which could result in some unauthorized benefit to him or her or another person, whether directly or indirectly, resulting in unnecessary costs to the program, improper payment, or program payment. Examples of fraud are: Billing for services that were not provided Incorrect reporting of diagnoses or procedures to get a higher payment (upcoding) Billing for covered services when non-covered services were provided Giving or getting kickbacks, bribes, rebates Routinely waiving deductible or coinsurance It may not be fraud if: HIICAP NOTEBOOK

3 A doctor took a sample or specimen and sent it to a laboratory Your client had X-rays and a doctor is reading the X-ray. Suspect fraud if: Your client is offered free testing or screening in exchange for their Medicare number. Your client is offered free medical equipment in exchange for their Medicare number. A provider routinely waives the 20 percent (20%) coinsurance or the deductible amount. Your client is offered free goods, such as a microwave oven, television, or air conditioner in exchange for their Medicare number. Someone comes to your client s door claiming to represent Medicare and offers them free services or goods in exchange for their Medicare number. Phone scams, including collect calls. The callers may identify themselves as employees of Medicare, the Social Security Administration (SSA) or a National Health Card. The caller usually is trying to get your client s MEDICARE or SOCIAL SECURITY number and their BANK ACCOUNT number. Is this fraud? Q. You and your wife, who uses a cane, attend a free health care screening at the local mall. In return for giving the staff your Medicare numbers, you get your blood pressure tested and receive some nutritional counseling information. A week later you get a call from a supplier who tells you that Medicare will give your wife a free wheelchair. The supplier tells you, Don t worry, we will get Medicare to approve it, and it won t cost you or your wife a cent. Is this fraud? A. This is definitely a fraudulent situation. A basic rule is to NEVER give your Medicare number out in return for a free service. This supplier is trying to make money by providing something the person does not really need. Only your physician can legitimately write a prescription for a wheelchair or other piece of durable medical equipment. In addition, using equipment that is not necessary and ordered by a physician might lead to diminished physical capacity and stamina and could even cause harm. Q. Your neighbor spends seven days in the hospital for surgery. After he is discharged, he gets a statement from a radiologist for interpretation of X-rays while he was in the hospital. The statement says that Medicare has been billed for the service. This is fraud! your neighbor angrily yells, I never saw any radiologist while I was in the hospital! I m going to call Medicare and tell them not to pay this bill. Is the radiologist guilty of fraud? A. There are times when physicians provide diagnostic and interpretative services to hospital patients even though the patient never sees them. If this radiologist s bill shows services provided during the same time frame as the hospital stay, it is probably legitimate. However, as always, you should review all bills and the Medicare Summary Notice and if you have any questions call Medicare. Abuse Abuse includes practices of providers, physicians, or suppliers that are inconsistent with accepted sound medical practices or for services that fail to meet professionally recognized standards of care, or are medically unnecessary HIICAP NOTEBOOK 11-3

4 Examples of abuse are: Unnecessary or excessive services Increasing charges to people with Medicare but not to other patients Improper billing practices: o Billing Medicare instead of a primary payer o Exceeding the limiting charge allowance People with Medicare usually owe 20 percent (20%) of the approved amount. Not accepting assignment means the provider does not accept Medicare s approved amount as payment in full. A provider cannot, however, charge whatever he or she chooses to people with Medicare. Federal and New York State laws usually limit how much a doctor may charge in excess of Medicare s approved amount. WHAT CAN YOUR CLIENT DO TO HELP? Never give out their Medicare number unless your client is SURE it is for legitimate reasons Protect their Medicare card as they would their credit card Read their Medicare Summary Notice (MSN) carefully report any discrepancies to SMP Keep a record of their doctor/lab appointments (National Government Services has a Monthly Personal Health Care Journal A Record for Checking Your Health Care Statement) to compare to their MSN Don t be a participant! Call SMP if they suspect fraud Beware of offers of free services or equipment only their provider should prescribe Durable Medical Equipment for your client Take special notice of MSNs from out of state did they receive that service? Call Medicare if their provider bills for a covered service when a non-covered service was provided Medicare does not pay for acupuncture or cosmetic surgery Beware of advertising that promises Medicare will pay for certain care or devices If someone comes to your client s door claiming to be from Medicare, remember that Medicare does not send representatives to their home Question phone calls or collect calls stating they are from Medicare, Social Security or another government office. If your client is offered free diagnostic tests, including stroke prevention studies, remember that all diagnostic tests should be ordered by their doctor Ask questions if: o your client does not understand the charges billed o your client does not think they received the service o your client feels the service was unnecessary Remember: When in doubt, let SMP check it out! PROTECT YOURSELF! HIICAP NOTEBOOK

5 Medicare Drug Integrity Contractor (MEDIC) The Centers for Medicare & Medicaid Services (CMS) has partnered with a Medicare Drug Integrity Contractor (MEDIC), Health Integrity, LLC, to fight fraud, waste and abuse in the Medicare Advantage (Part C) and Prescription Drug (Part D) programs. The MEDIC is committed to partnering with you to prevent inappropriate activity in the Medicare Part C and D programs. The National Benefit Integrity (NBI) MEDIC, Health Integrity, handles activities such as: Criminal violations of law Kickbacks, fraud schemes Billing for services not rendered Requests for data or information to support ongoing law enforcement investigations If you wish to report an incident of fraud, waste and abuse associated with Medicare Part C or Part D, please contact the NBI MEDIC at SafeRx ( ) to report complaints about one of these issues or a related complaint. To protect beneficiaries against prohibited and high-pressure marketing tactics, CMS needs your help monitoring and preventing inappropriate marketing activities like these: Public/Marketing Sales Events Plan representatives communicating incorrect information about their plan type (MAPD HMO/PPO, PDP, Special Needs Plans, etc.) A plan or agent using pressure tactics (for example, requiring a beneficiary to provide contact information to attend a public marketing/sales event) Meals served at public sales events to entice beneficiaries to enroll in a plan Newspaper/Print Ads Ads conveying inaccurate information, using inappropriate language or absolute statements without supporting data (e.g., Plan X is the best or highest ranked plan in the nation) Ads missing the required material ID number and CMS approval (e.g., Y1234_drugx38 CMS Approved MMDDYYYY or H1234_0021 File & Use MMDDYYYY ) Social Media Marketing (Agent Blogs, Facebook, Twitter, YouTube, etc.) Steering beneficiaries into a particular plan when information on multiple plan sponsors is available Asking beneficiaries for banking information on social media networking sites (Facebook, Twitter, etc.) Note: Social Media sites regularly ask for personal information, but NOT banking information. We re specifically looking for people using social media to solicit personal banking information from beneficiaries HIICAP NOTEBOOK 11-5

6 Rogue Agent/Broker Behavior Asking for personal or Medicare information through unsolicited telephone calls or home visits Marketing plans or conducting enrollments during educational events like health fairs and conferences Selling non-health-related products, like an annuity or life insurance policy, while marketing a Medicare health or drug plan How to Report Suspicious Marketing Activities your CMS Regional Office SHIP (State Health Insurance Assistance Program) Liaison or CMS Regional Office DFS (Department of Financial Services) Liaison detailing the observation or activity (who, what, where, when, and how). If it s online or in a newspaper/print ad, provide the website address or the newspaper name and date, as well as the information marketed and requested; OR Complete and submit the Targeted Observation (TO) tool to your DFS Liaison. Fill in all applicable fields and provide details of your observations. For an electronic copy of the TO tool, contact your DFS Liaison, Harold Goodwin or Additional Resources Publications: Protecting Medicare and You from Fraud (CMS 10111) (October 2011) Help Prevent Fraud - Check Your Medicare Claims Early! (CMS 11492) (March 2014) o You Can Help Protect Yourself and Medicare from Fraud Committed by Dishonest Suppliers (CMS 11442) (March 2014) 4 R s for Fighting Medicare Fraud (CMS 11610) (March 2014) HIICAP NOTEBOOK

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